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K0918

Sprinkler Head Installed Too Close to Light Fixture

Bay City, Michigan Survey Completed on 06-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to provide a sprinkler system installed in accordance with NFPA 13 requirements. Specifically, during an inspection, it was found that the sprinkler head located in the main lobby near the front egress door was positioned too close to a light fixture. This proximity was determined to be within a few inches, which does not comply with NFPA 13, 8.3.2.5, Table 8.3.2.5(c), as it could alter the water flow pattern and prevent proper sprinkler protection. These findings were confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of observation.

Plan Of Correction

Element 2: An audit of the facility determined that 3 additional light fixtures are located too close to the sprinkler heads. Element 3: Electrician is scheduled to move overhead lights to be completed by 7/24/2025. Element 4: EVS Director or designee will audit sprinkler heads weekly to ensure that they are not blocked and provide proper sprinkler protection. Results will be brought to weekly QA for review and recommendations. EVS Director is responsible for compliance.

See complete original report
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